We are here to assist family members and our Professional Partners with the most convenient and seamless admit process possible -
24 hours a day, 7 days a week!
For direct personal service, please contact Charles Killion, NFA, Administrator, at 504-913-2248 (cell) or CKillion@CrescentCityCare.com
Required information is marked with an asterisk (*).
* Your Name:
* You Are A:
Case Manager / Discharge Planner
Family Member
* Your Telephone Number:
(555-555-5555)
* Your Email Address:
Your Position:
Your Facility:
Patient's Name:
Date of Birth:
(MM-DD-YYYY)
Social Security Number:
(555-55-5555)
(for Medicare Day(s) confirmation)
* Gender:
Female
Male
* Type of of Care Level / Room Desired (Please Check the Appropriate Type):
Skilled:
Private Semi-Private N/A
Alzheimer's:
Private Semi-Private N/A
Intermediate Care:
Private Semi-Private N/A
Rehab Care:
Private Semi-Private N/A
* Form of Payment:
Medicaid
Medicaid Pending
Medicare
Managed Care
Long Term Care Insurance
Private Pay
Other Co-Insurance
* Clinical Services Needed
(In Brief):
We are here to serve you!
From the Staff of Crescent City Health Care Center
